N.J. Admin. Code § 11:22-1.10

Current through Register Vol. 56, No. 21, November 4, 2024

Section 11:22-1.10 - Internal appeals-health carriers

(a) Every health carrier or its agent shall establish an internal appeals mechanism to resolve payment disputes between health carriers or their agents and health care providers, but not including appeals related to medical necessity made pursuant to 11:24-8.5, 8.6, and 8.7 and 11:24A-3.5, 3.6, and 3.7. The internal appeals mechanism shall be described in the participating provider contract and in a publicly available internet website.

1. A health care provider may initiate an appeal of a health carrier's or its agent's claim determination:

i. Within 90 calendar days of receipt of the health carrier's or agent's determination that is the basis of the appeal; or

ii. Within 90 calendar days of a health carrier's or its agent's missed due date for the claim determination, including at the provider's option, a claim that has been pended.

2. A provider shall initiate an appeal by submitting to the health carrier or its agent a complete Claim Payment Appeal Form, which shall include all substantiating documentation required by the health carrier or its agent. The carrier or its agent shall not reject an appeal based on the provider's failure to notify his or her patient of the appeal. The application form and instructions, which require the applicant to submit the name and contact information, the patient's name and the claim number with a description of the reason for appeal, are available for download on the Department's website at www.dobi.nj.gov. A health carrier or its agent may make available the application form and instructions on its website to allow for electronic submission of applications.

3. The health carrier or its agent shall conduct a review of the internal appeal and notify the health care provider of its determination within 30 calendar days of receipt of the application for internal appeal. The internal review shall be conducted by employees of the health carrier or its agent who shall be personnel other than those responsible for claims payment on a day-to-day basis and shall be provided at no cost to the provider. If the carrier or its agent fails to notify the provider of its determination within 30 calendar days of receipt of the application, the provider may initiate an arbitration proceeding in accordance with 11:22-1.13(c).

4. The health carrier or its agent shall communicate the results of the internal review in a written decision to the provider, which shall include:

i. The names, titles, and qualifying credentials of the person or persons participating in the internal review;

ii. A statement of the provider's grievance;

iii. The decision of the reviewer(s), together with a detailed explanation of the basis for such decision;

iv. A description of the substantiating documentation, which supports the decision;

v. If the payment decision is adverse to the health care provider in any respect, a description of the method to obtain an external review of the decision by arbitration pursuant to 11:22-1.13; and

vi. If the decision favors the health care provider in any respect, the health carrier or its agent shall be required to pay within 30 calendar days of the date of issuance of the health carrier's or its agent's determination of the internal appeal, the amount due as determined by the internal appeal, if applicable, with accrued interest at the rate of 12 percent per year calculated from the date of receipt of the internal appeal by the health carrier or its agent at its designated address.

N.J. Admin. Code § 11:22-1.10

Amended and recodified from 11:22-1.11 by 50 N.J.R. 571(a), effective 1/16/2018

Amended by 50 N.J.R. 829(a), effective 2/5/2018